Direct Venous ReconstructionHistorically, the first successful procedures done to reconstruct major veins were the femorofemoral crossover graftof Eduardo Palma and the saphenopopliteal bypass described by him and used also by Richard Warren of Boston.[31] These operations were elegant in their simplicity,use of autogenous tissue, and reconstruction by a single venovenous anastomosis.With regard to femorofemoral crossover grafts, the only group to provide long-term physiologic study of a large number of patients is Halliday and colleagues fromSydney, Australia.[32] Although phlebography was used in selecting patients for surgery, no other details of preoperative indications are given. They were able todocument that 34 of 50 grafts remained patent in the long term as assessed by postoperative phlebography. They believed the best clinical results were achieved inrelief of postexercise calf pain, but they had the impression that a patent graft also slowed the progression of distal liposclerosis and controlled recurrent ulceration. Noproof of this was given in their report. The history of application of bypass procedures for venous obstruction is a fascinating one. Nevertheless, the advent ofendovascular techniques has made those operations nearly obsolete.[33]Perforator interruption combined with superficial venous ablation has been effective in controlling venous ulceration in 75% to 85% of patients. However, emphasis onfailures of this technique led to Kistner’s significant breakthrough in direct venous reconstruction with valvuloplasty in 1968 and the general recognition of thisprocedure after 1975.[34] Late evaluation of direct valve reconstruction indicates good to excellent long-term results in more than 80% of the patients.[35]One cannot overestimate the contributions of Kistner. The technique of directing the incompetent venous stream through a competent proximal valve via venoussegment transfer was his next achievement. After Kistner’s contributions, surgeons were provided with an armamentarium that included Palma’s venous bypass, directvalvuloplasty (of Kistner), and venous segment transfer (of Kistner). Moreover, external valvular reconstruction as performed by various techniques, includingmonitoring by endoscopy, holds the promise of a renewed interest in this form of treatment of venous insufficiency.Axillary-to-popliteal autotransplantation of valve-containing venous segments has been considered since the early observations of Taheri and colleagues.[36] Verificationin the long term of some preliminary excellent results has not been accomplished.The advent of perforator vein surgery and the fine results achieved with it have displaced direct valvuloplasty into a position of less importance and even less interestthan the procedure had called for during the 1980s.